COVID-19 associated diarrhea differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2] Ifrah Fatima, M.B.B.S [3]

Overview

COVID-19 diarrhea must be differentiated from diarrhea due to other organisms such as secondary bacterial infections, Clostridium difficile associated diarrhea, Viral causes and parasitic causes. ^[1]

Differential Diagnosis

Organism			Age predilection	Travel History	Incubation Size (cell)	Incubation Time	History and Symptoms			Diarrhea type∞				Food source	Specific consideration
Organism			Age predilection	Travel History	Incubation Size (cell)	Incubation Time	Fever	N/V	Cramping Abd Pain	Small Bowel	Large Bowel	Inflammatory	Non-inflammatory	Food source	Specific consideration
Viral	Rotavirus		<2 y	–	<10²	<48 h	+	+	–	+			+	–	Mostly in day cares, most common in winter.
	Norovirus		Any age	–	10 -10³	24-48 h	+	+	+	+			+	–	Most common cause of gastroenteritis, abdominal tenderness,
	Adenovirus		<2 y	–	10⁵ -10⁶	8-10 d	+	+	+	+			+	–	No seasonality
	Astrovirus		<5 y	–		72-96 h	+	+	+	+			+	Seafood	Mostly during winter
Bacterial	Escherichia coli	ETEC	Any age	+	10⁸ -10¹⁰	24 h	–	+	+	+			+	–	Causes travelers diarrhea, contains heat-labile toxins (LT) and heat-stable toxins (ST)
		EPEC	<1 y	–	10^†	6-12 h	–	+	+	+			+	Raw beef and chicken	–
		EIEC	Any ages	–	10^†	24 h	+	+	+		+		+	Hamburger meat and unpasteurized milk	Similar to shigellosis, can cause bloody diarrhea
		EHEC	Any ages	–	10	3-4 d	–	+	+		+	+		Undercooked or raw hamburger (ground beef)	Known as E. coli O157:H7, can cause HUS/TTP.
		EAEC	Any ages	+	10¹⁰	8-18 h	–	–	+		+		+	–	May cause prolonged or persistent diarrhea in children
	Salmonella sp.		Any ages	+	1	6 to 72 h	+	+	+		+	+		Meats, poultry, eggs, milk and dairy products, fish, shrimp, spices, yeast, coconut, sauces, freshly prepared salad.	Can cause salmonellosis or typhoid fever.
	Shigella sp.		Any ages	–	10 – 200	8-48 h	+	+	+		+	+		Raw foods, for example, lettuce, salads (potato, tuna, shrimp, macaroni, and chicken)	Some strains produce enterotoxin and Shiga toxin similar to those produced by E. coli O157:H7
	Campylobacter sp.		<5 y, 15-29 y	–	10⁴	2-5 d	+	+	+		+	+		Undercooked poultry products, unpasteurized milk and cheeses made from unpasteurized milk, vegetables, seafood and contaminated water.	May cause bacteremia, Guillain-Barré syndrome (GBS), hemolytic uremic syndrome (HUS) and recurrent colitis
	Yersinia enterocolitica		<10 y	–	10⁴ -10⁶	1-11 d	+	+	+		+	+		Meats (pork, beef, lamb, etc.), oysters, fish, crabs, and raw milk.	May cause reactive arthritis; glomerulonephritis; endocarditis; erythema nodosum. can mimic appendicitis and mesenteric lymphadenitis.
	Clostridium perfringens		Any ages		> 10⁶	16 h	–	–	+		+		+	Meats (especially beef and poultry), meat-containing products (e.g., gravies and stews), and Mexican foods.	Can survive high heat,
	Vibrio cholerae		Any ages	–	10⁶-10¹⁰	24-48 h	–	+	+	+			+	Seafoods, including molluscan shellfish (oysters, mussels, and clams), crab, lobster, shrimp, squid, and finfish.	Hypotension, tachycardia, decreased skin turgor. Rice-water stools
Parasites	Protozoa	Giardia lamblia	2-5 y	+	1 cyst	1-2 we	–	–	+	+			+	Contaminated water	May cause malabsorption syndrome and severe weight loss
		Entamoeba histolytica	4-11 y	+	<10 cysts	2-4 we	–	+	+		+	+		Contaminated water and raw foods	May cause intestinal amebiasis and amebic liver abscess
		Cryptosporidium parvum	Any ages	–	10-100 oocysts	7-10 d	+	+	+	+			+	Juices and milk	May cause copious diarrhea and dehydration in patients with AIDS especially with 180 > CD₄
		Cyclospora cayetanensis	Any ages	+	10-100 oocysts	7-10 d	–	+	+	+			+	Fresh produce, such as raspberries, basil, and several varieties of lettuce.	More common in rainy areas
	Helminths	Trichinella spp	Any ages	–	Two viable larvae (male and female)	1-4 we	–	+	+		+		+	Undercooked meats	More common in hunters or people who eat traditionally uncooked meats
		Taenia spp	Any ages	–	1 larva or egg	2-4 m	–	+	+	+			+	Undercooked beef and pork	Neurocysticercosis: Cysts located in the brain may be asymptomatic or seizures, increased intracranial pressure, headache.
		Diphyllobothrium latum	Any ages	–	1 larva	15 d	–	–	–	+			+	Raw or undercooked fish.	May cause vitamin B₁₂ deficiency

∞Small bowel diarrhea: watery, voluminous with less than 5 WBC/high power field

Large bowel diarrhea: Mucousy and/or bloody with less volume and more than 10 WBC/high power field

† It could be as high as 1000 based on patient’s immunity system.

References

↑ Occhipinti V, Pastorelli L (2020). “Challenges in the Care of IBD Patients During the CoViD-19 Pandemic: Report From a “Red Zone” Area in Northern Italy”. Inflamm Bowel Dis. 26 (6): 793–796. doi:10.1093/ibd/izaa084. PMC 7188155 Check |pmc= value (help). PMID 32314792 Check |pmid= value (help).

[pmid32314792-1] Occhipinti V, Pastorelli L (2020). “Challenges in the Care of IBD Patients During the CoViD-19 Pandemic: Report From a “Red Zone” Area in Northern Italy”. Inflamm Bowel Dis. 26 (6): 793–796. doi:10.1093/ibd/izaa084. PMC 7188155 Check |pmc= value (help). PMID 32314792 Check |pmid= value (help).

[1]

COVID-19 associated diarrhea differential diagnosis

Overview

Differential Diagnosis

References

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